1. Maternal Mortality MICS3 Data Analysis and Report Writing

2. Background The complications of pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. Women whose growth has been stunted by chronic malnutrition are vulnerable to obstructed labour. Anaemia predisposes women to haemorrhage and sepsis during delivery. And maternal risk is even greater for women who have undergone female genital mutilation.

3. Background Causes of maternal mortality include post-partum haemorrhage, sepsis, complications of unsafe abortion, prolonged or obstructed labour and the hypertensive disorders of pregnancy, especially eclampsia. Prompt access to quality obstetric services equipped to provide lifesaving drugs, antibiotics and transfusions and to perform the caesarean sections and other surgical interventions that prevent deaths from obstructed labour, eclampsia and intractable haemorrhage is needed.

4. International Goals & Targets Between 1990 and 2015 reduce by three-quarters the maternal mortality ratio Reduction in the maternal mortality ratio by at least one- third, in pursuit of the MDG of reducing it by three-quarters by 2015

5. Definition of Indicator Maternal mortality ratio Numerator: Number of deaths of women from pregnancy- related causes in a given year Denominator: Number of live births in a given year (expressed per 100,000 live births)

6. Methodological Issues Sources of data for maternal mortality Vital Registration systems Reproductive Age Mortality Studies (RAMOS) Household Surveys - Direct Methods - Sisterhood methods - Direct - Indirect

7. Methodological Issues Definition of a maternal death Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

8. Methodological Issues Problems in measuring maternal mortality Requires information on: Pregnancy status Timing of death (within 42 days of termination of pregnancy) Cause of death Each of these elements is difficult to measure!

9. Methodological Issues Problems in measuring maternal mortality Vital registration systems: Underreporting Misclassification In most developed countries with complete vital registration, misclassification and underreporting, causes estimates to be underreported by a factor between 1.5 and 3.

10. Methodological Issues Problems with measurement Household Surveys: Maternal mortality is a relatively rare event When household surveys are used, huge sample sizes are required Example: To estimate an MMR of 300 within a 20% margin of error requires a sample of 50,000 births (may imply much larger number of households)

11. Methodological Issues Sisterhood Method (indirect) Advantages Reduces sample size requirements Minimal data requirements (5 questions only) Simple data processing and analysis Disadvantages Results reflect a point in time approximately 12 years before the survey Wide confidence intervals – cannot be used to measure trends in the short term

12. Methodological Issues Sisterhood Method (indirect) How many sisters (born to the same mother) have you ever had? How many of these sisters ever reached age 15? How many of these sisters (who are at least 15 years old) are alive now? How many of these sisters who reached age 15 or more have died? How many of these dead sisters died while they were pregnant, or during childbirth, or during the six weeks after the end of pregnancy?

13. Methodological Issues Eligibility for Sisterhood Method (indirect) If there is no reliable estimate for maternal mortality If an approximate level of maternal mortality is needed for advocacy purposes and to draw attention to the problem Remember: Because of large confidence intervals around the estimates, the results are not suitable for assessing trends over time.

14. Methodological Issues MMR = 100,000 [1 – (1 – LRMD) exp 1/ TFR] where, LRMD is the lifetime risk of maternal death TFR is the total fertility rate estimated for the 10-14 years prior to the survey

15. Methodological Issues The adjustment factors are standard and reflect, for each age group, the proportion of womens reproductive life exposed to the risk of maternal mortality Sisters aged 15+ for the first three age groups are adjusted to be equal to the number of respondents in the age group times the average number of sisters to respondents aged 30+

16. Tabulation Plan Table RH.6: Maternal Mortality Ratio

17. Regional Maternal Mortality

18. Maternal Mortality (ROSA)

19. Maternal Mortality (TACRO)

20. Maternal Mortality (MENA)

21. Maternal Mortality (CEE/CIS)

22. Maternal Mortality (EAPRO)

23. Maternal Mortality (ESARO)

24. Maternal Mortality (WCARO)